We’re all in this Together!

Moving From Good to Great!

CARF UpdateJune 2014

Agenda

•Welcome •Review Learning Objectives•Discuss New/Revised Policies and

New/Revised Forms•Short Quiz •Questions & Answers

Learning Objectives

•At the end of this session you will be able to:

•Identify new policies and or policy changes.•Name at least three new forms that have

been added to the administration of our patients.•Describe changes to existing forms and

explain the purpose of the changes.

Why Are We Having This Training?

As a result of our CARF Certification several recommendations were made by CARF as it relates to the management of our business. Today we will review our corrective actions and/or our solutions to those proposed recommendations.

Why Are We Having this Training? – Cont.

•Keep in mind, the changes range from: A slight modification to an existing form A new form Or new policy

• No matter how big or small the change we want to ensure we all have the same information.

Let’s Review Policy Changes and Clarifications First!

•Technology Plan•Conflicts of Interest•Inclement Weather•Training & Development

Technology Plan

• Kolmac will begin to evaluate the need for assistive technology at least once per year.

• Kolmac will also evaluate the need for assistive technology at any point deemed necessary such as the hiring of a staff member with disabilities or the admission of a patient with disabilities.

Conflicts of Interest• Licensed clinicians can only do private practice with

active Kolmac patients if;

1. the patient is not attending the same office the clinician works and it is approved by the Clinical Director.

2. the clinician works less than 4 hours per week and it is approved by the Clinical Director.

See Handout for the entire Conflict of Interest Policy

Conflicts of Interest

• Clinical Directors and Asst. Directors may not do private practice with any Kolmac patient, regardless of what office the patient is in, unless they originally referred the patient to Kolmac.

See Handout for the entire Conflict of Interest Policy

Inclement Weather• In the event a non-exempt employee’s office is closed,

or the office is open but staff do not feel safe coming into work due to the weather, non-exempt employees will either need to take Leave Without Pay (LWOP) or use Paid Time Off, if they are eligible for PTO.

• If your office is closed by Corporate all non-exempt employee’s who are eligible for PTO and who were not previously scheduled off, will be paid their regularly scheduled hours.

Training and Development

• In Service Training may assist licensed staff with obtaining the required continuing education units (CEU’s) in their respective fields.   

• Instructions on how to print a training log or In-Service Certificate is included in the training and development policy (see handout).

•

Now It’s Time to Review the Forms…

The date the form was created or revised

should be at the bottom of the form.

Rev. 5/12/14 etb

It may be on the Left or Right of the form!

RE: 5/15/2014

New: Patient Emergency Information Card

Next Print - Patient Emergency Information Card

First Name Last Name

6/16/14

New- Patient Emergency Information Card Process

•Patient Emergency Information Cards will be stored in a Black Index Card Box in a secured location.

•When evacuating the building, staff will take; The Black Index Card Box The Health and Safety BinderThe roster of any groups in session

New- Patient Emergency Information Card

• Admin is responsible for having the patient complete the Patient Emergency Information Card at orientation and for weekly updates.

The Black Index Card Box should be updated weekly

by; checking to ensure every active patient has a card and removing any inactive patients cards.

Cards of patients who are no longer with the Kolmac Clinic should be removed from the Black Index Card Box and placed in the patients file.

Change: Clinical Supervision Form

Add

ed

On Page 2 of 2

Added to Patient Orientation

Patient Orientation Checklist FormShowing patients the emergency exits,

location of the fire suppression equipment, first aid supplies and the restrooms. 

Showing patients at least one of our posted evacuation plans and informing the patient that the plans can be found in every office near the door. 

New: Patient Orientation Checklist

New: Patient Orientation Checklist

What happens with the Patient Orientation Checklist once completed…

New: Brief Initial Screening Form3 pages

Change: Psychosocial Evaluation Form

Page 2 of 7

Change: Psychosocial Evaluation Form

AD

DED

Page 2 of 7

WE WILL REVIEW A PATIENT SAFETY PLAN FORM NEXT

Change: Psychosocial Evaluation Form

Page 2 of 7

Change: Psychosocial Evaluation Form

Page 3 of 7

Change: Psychosocial Evaluation Form

Page 3 of 7

Change: Psychosocial Evaluation Form

Page 4 of 7

Change: Psychosocial Evaluation Form

Page 4 of 7

Change: Psychosocial Evaluation Form

Page 5 of 7

ADDED

Change: Psychosocial Evaluation Form

Page 5 of 7

Change: Psychosocial Evaluation Form

Page 6 of 7

ADDED

Change: Psychosocial Evaluation Form

Page 7 of 7AD

DE

D

ADDED

New: Patient Safety Plan (Referenced under Harm to Self on Psychosocial Evaluation)

New: Patient Safety Plan

•Do patients get a copy of this form?

•When should you do a new Patient Safety Plan for a patient?

•Do you need releases for those contacts listed on the Patient Safety Plan?

Change: Person Centered IOP PlanAdded

Page 2 of 6

Change: Person Centered IOP Plan

Page 3 of 6

Change: Person Centered IOP Plan

Page 3 of 6

Change: Person Centered IOP PlanPage 4 of 6

Change: Person Centered IOP PlanPage 5 of 6

Change: Person Centered CC Plan

On all 6 pagesSAME FORMAT &

PROCESS

AS THE IOP PLAN

Change: Chart Review FormPage 1 of 2

Change: Chart Review FormAdded

4. The goals and service/treatment objectives of the persons served were:a. Based on:1. The results of the

assessments………………………………….....2. The input of the persons served as evidenced by;a. Completion of the IOP

SNAP..................................................b. The use of person first language on the IOP Tx

Plan……….c. Completion of the CC SNAP…………………………………d. The use of person first language on the CC Tx

Plan…………1. Revised when indicated, as evidenced by:a. Timely updates on IOP Tx Plan……………………………..b. Timely updates on CC Tx Plan………………………………

Page 2 of 2

Change: Chart Review Form

7. The person-centered plan was reviewed and updated in accordance with the Organization’s policy, as evidenced by;a. Timely completion of the IOP Tx Plan (within 14 days

of admission)b. IOP Tx Plan is signed by a LICENSED

clinician……………………c. Timely completion of the CC Tx Plan (before

admission into CC)….d. CC Tx Plan signed by a licensed

clinician……………………………

Added Page 2 of 2

Change: Transition SummaryPage 1 of 2

Change: Transition SummaryAdded Page 2 of 2

Change: Transition Summary

Page 2 of 2

Change: Recovery Plan

Change: Grievance Procedure Form

Distributed at Patient Orientation

ADDED

Change: Admission Medical Review Form

Page 1 of 2

New: Pregnancy Test Acknowledgement

Used before the administration of medications for withdrawal management patients located on the bottom of the Admission Medical Review Form

Page 2 of 2

New: Supervision Acknowledgement

Change: IOP/CC Individual Session Note

Page 1 of 2

Question:•Can you name the policies that we have added

and/or revised?

•Technology Plan•Conflicts of Interest• Inclement Weather•Training and Development

Question:•Can you name at least one new form/process that has

been added to the administrative management of our patients?

• Patient Emergency Information Card• Patient Orientation Checklist• Brief Initial Screening Form• Patient Safety Plan• Pregnancy Test Acknowledgment on the Medical

Review Form• Supervision Acknowledgement Form

Question:

•What two instances should the Transition Summary form be used?

1. For patients transferring from one level of care to another

2. For patients transferring from one office to another

Question:•What is new to the Patient Orientation Process?

•Showing patients the emergency exits, location of the fire suppression equipment, first aid supplies and the restrooms.

•Showing patients at least one of our posted evacuation plans and informing patients that plans can be found in every office near the door.

•The Patient Orientation Checklist Form

Question:•What is the purpose of the Patient Orientation

Checklist?

•This form assist us with documenting our patient orientation process.

Question:•When should the Patient Safety Plan form be

used?

•To be completed by the Clinician (at any time) if the patient is at risk for dangerous behaviors

Question:•The Initial Patient Screenings Form eliminates what

screens?

•Beck•Brown ADD Scale•MDQ •Dissociative Experience Scale

Question:•Does the IOP Session Note replace the Case

Management Notes?

•Yes

Question:•We now have a Session Note for both:

• IOP and CC

Question:• Can you name what has changed as a result of our CARF

accreditation or as a part of our “Good to Great” model?

• Clinical Supervision Form • Psychosocial Evaluation Form• Person Centered IOP Plan• Person Centered CC Plan• Clinical Chart Review• Transition Summary• Recovery Plan• Grievance Procedure Form• Admission Medical Review Form• IOP Individual Session Note

Questions and Answers